To ensure transparency and encourage open dialogue, the feedback we receive is posted on our website in accordance with our posting guidelines.
Current month ye@r day *
Leave this field empty *
I am a general surgeon in Ontario. I always obtain verbal informed consent for a proposed surgical treatment (eg. appendectomy). In the past, we have written in the patient’s orders that the patient has consented, but have had the nurses obtain the patient’s signature on the hospital’s written consent form. Many of the nurses now claim that is inappropriate, and that it is outside their scope of practice to witness the patient signing this form. They insist the filling in and signing of the form is a key element of the physician’s responsibility around obtaining consent. Can others please comment on this issue, and can college representatives please comment on their expectations.
Verbal consent is the basis of valid consent. The written consent is a mere bit of evidence that that discussion took place. Physicians ought to be careful in delegating the consent discussion to someone else. One reason for some medical mistakes (e.g., wrong side surgery) is that MDs were not sufficiently vigilant about what the patient had consented to….
This a matter that should be addressed by the College of Nurses of Ontario.
I believe that there is a misunderstanding as to the role of witnesses to the signature on a legal document. The witness only needs to confirm that the signature was executed by the person named and perhaps that the person appeared to be “of sound mind” at the time the document has been signed.
Any legally responsible person can witness a signature.
There may be times when a nurse is actually present during the consent process. The nurse would then be in a position to address the content of the information conveyed and the patient’s responses.
This second scenario needs to be more fully addressed.
I agree that it is the physician’s responsibility to complete the consent form with the patient and that this task should not be delegated to anyone else. Also, a full list of risks and alternatives needs to be on the consent form so that if any of the important risks are missed in the verbal discussion between physician and patient, they are present on the consent form for the patient to review before signing.
I agree. It is the physician’s responsibility to fill out the consent form with the patient and all risks and benefits should be clearly laid out on the consent form.
It is the responsibility of the physician to complete the consent form with the patient and all risks should be listed on the consent form.
no need for change
I am a speech-language pathologist (SLP) and completed my doctorate from the (identifying information removed) on capacity evaluation with people with aphasia and other communication barriers.
I would strongly recommend that in an emergency situation, when a physician has to obtain consent from a patient with aphasia or any other communication barrier, that the physician requests the SLP be involved. SLPs have the knowledge, skills and judgement to overcome many communication barriers and to help the physician determine capacity to consent or otherwise.
Consider recommendations about how to approach covert medication administration (currently used most in geriatric or dual diagnosis programs)? For incapable persons with Public Guardian and Trustees, the route of such administration is not addressed/commented on by PGTs although discussion is often had with family members about this. Importance of seeking ethics consultation and documentation of rationale could be included.
Regarding the current CPSO request for professional opinion re Consent guidelines which are in the process of being updated:
I have been my mother’s SDM for 6 years. She is (identifying information removed) deemed incapacitated and has resided in an LTC (identifying information removed) for 6 years.
I am a practicing [physician]. I have been intimately involved in her care for these 6 years – and even earlier for the 4 yr previous after my father’s death.
My sister and I recently submitted a complaint (identifying information removed) re her nursing home. One issue was that the nursing home did not always inform me of medication changes – including changes in dosages and dosage protocols which I deemed important in her care. These changes were effected by following doctor’s orders at the LTC. However, the doctor and the LTC both told me that it was the responsibility of the LTC to inform me of any changes.
In discussing this [I was] informed that in fact, according to LTC regulation, the doctor and home can make dosages changes and Rx protocol changes without informing me as SDM.
As a practicing physician (identifying information removed), I feel that the current guidelines tell me that I cannot administer changes in medication without the patient’s consent. Also, in the current CPSO guideline, there is a section which I felt was clear that an SDM I should be informed as to what Rx changes are made for an incapacitated patient.
So, this seems a discrepancy in my view, that apparently LTC regulation and CPSO expectation are at variance, and clarification is at least necessary.
In my own case as SDM for my mother, I personally and professionally feel as SDM I am an informed SDM and should be consulted when my mother’s physician orders medication changes for her.
As well, when my mother was hospitalized at [hospital 1] I was told there, that they do not have to inform me of dosage changes to existing medications. This also seems contrary to the existing guidelines, never mind that it is bad bedside manner. In contrast, when she was recently hospitalized at [hospital 2], I was informed of all MD suggestions regarding medication, and consent was expected by the medical team, which in my view is the at least the intention of Consent, if not the precise legalistic interpretation. Again, it is my opinion that clarification of these overlapping areas of medical practice needs clarification ( ie private practice, hospital protocol, and LTC protocol and expectation).
in the area of informed consent it states that the physician has explained ‘alternative courses of action”
I think the document should have a separate sentence to emphasize this point especially now that therapies have become more complex. I was comanaging a patient who was offered biologic therapy for a disease that was also ammenable to surgery. The possibility of surgery was not discussed. I believe it is the patients decision even if one treatment or another were strongly recommended depending on the circumstance. Again, I dont think your statement is worded strongly enough.
When considering aggressive therapy, all reasonable alternataive treatments (medical or surgical) should be discussed.
As a medical i.e. non-surgical specialist, serving as a consultantant it is often assumed that the referring physician and the patient have decided on a non-surgical approach. Had the preference been for surgery, the referral would have been directed to a surgeon.
There is considerable variation in the practices of individual surgeons; a patient who is deemed to ba a good surgical candidate by one surgeon may be viewed as a poor candidate by another. A patient’s suitability as a surgical candidate may be difficult for a non-surgeon to evaluate.
I know from speaking to my colleagues that many of us feel frustrated with the idea of informed consent as it practiced at the moment. Patients background knowledge (or lack there of ) makes it very difficult for them to make a decision based on a good understanding of all the aspect of the procudure.
I feel strongly that there should be standardized information sheet in language that present standard of care regards as logical and clear for the average patient. Informed consent should then consist of the patient reviewing this information sheet (after speaking to the doctor about the procedure or treatment ) and signing each page or maybe each item to indicate that it was read and that it is understood. The bottom of the sheet can then include a sentence saying that patient has reviewed this and opt to proceed with the surgery.
Documenting in your notes that you have explains the risks including this that and that occurring at such and such percentages (some physician states including but not limited) leaves no proof that any of this was actually discussed. Even if it was truly discussed it is rare that the patient can take all that info in and process it in the time of the clinical visit.
The idea of the written informed consent document should move away from providing a document that “covers my ass” should something go wrong. It should be document that aims to prepare the patient for understanding the challenges of the procedure as it relates to recovery and post op complications. It such be done in such a way that the patient ends up with realistic expectation of the possible outcome of the procedure. I feel that a standardized document will be more powerful that if each physician compiles his own document. It will truly set a standard of care.
“The idea of the written informed consent document should move away from providing a document that “covers my ass” should something go wrong.”
“…a standardized document will be more powerful that if each physician compiles his own document. It will truly set a standard of care.”
Fraud should not be permitted and promoted.
I believe that consent procedures are outdated. They often simply ask the patient to agree to do whatever needs to be done, and their purpose seems to be to free the doctor of liability in case things go wrong. Often consent is requested without providing a clear understanding of alternatives or a realistic description of the experience the patient will have. Increasingly there is a move to share the decision procedure so that patients and doctors come to a shared agreement about realistic alternatives, what will happen, how the patient will. For this no consent form must be radically altered to include experiential information as well as risks and a great deal of clarity about who will actually perform the procedure.
Some have already argued that when careful shred decisions are made about critical decisions, no consent form should be required at all, but an open and well developed decision procedure should be established.
Could there be some policy regarding the need to obtain translators for informed consent if the patient does not speak the language, and whether family members can be used for this purpose or must a 3rd party translator be used (in case the family member is withholding information from the patient).
Good point. I have used a medical translator when available in the office, or called a professional translation service. Using a family member may lead to trouble as there are privacy concerns, and the family member may not know how to translate medical terms, which may lead to mis-translations and uninformed consent.
In Canada, the official languages are English and French.
Dealing with patients who are not fluent in one of the official languages poses special problems. There could be many opinions on how to resolve them.
However, is is very unclear how translators are to be qualified and how it is that they will be reimbursed for their services. For some minority language groups finding qualified translators and having them available when required can be challenging.
In some cases I understand enough of the patient’s language to know that the translation is not completely accurate and is biased. This is a particular issue with family members who might (understandably) have their own opinions and concerns. However, it has sometimes occurred with professional translators.
Just to give some feedback,
In reviewing the consent policy it would be helpful to CLEARLY define ALL circumstances when consent is NOT required, like reporting epilepsy, what about alcoholism and driving, threatening to do harm for the psychiatrist.
I would personally like to see some guidelines on consent relating to critical care. Many routine procedures(central line- bronchoscopy,paracentesis, chest tube, etc. ) are not without risk, yet different hospitals seems to have different requirements for patients within and outside ICU. Can we get some guidance on how to bundle these items into one consent form / process?
Current guidelines adequate
I think there should be a defined minimum age at which a patient can provide consent in a non-emergency situation. There is a minimum age for a substitute decision-maker (16 years old), why not for the patient? I think the current wording in the current Consent to Medical Treatment guideline is too vague.
The Consent Policy is generally very good. I prefer ‘Choice’ over ‘Consent’, as the latter makes a presumption that the patient should go along with the proposed intervention (hence, ‘consenting’ the patient becomes the major objective) and if he / she doesn’t, then their capacity will be assessed. But ‘Dissent’ from treatment may be as reasonable as accepting a treatment recommendation. Treatment refusals that are likely to endanger patients ought to be carefully assessed for any ‘reversible’ factors.
Consent given by a patient to authorize medical care of any type should be INFORMED, VOLUNTARY, and COMPETENT. If a medical intervention goes well, everyone is happy and the consent permitting the intervention probably will never come up. If on the other hand the intervention goes badly the consent may be very carefully scrutinized as to its completeness and correctness with possible serious professional and medical-legal ramifications to the health care provider. It is then that the good doctor wishes all the “consent” elements were fully addressed with the patient and documented in the patient’s chart/file. Having another member of the health care team get a signed consent form may not be enough to guarantee that proper consent was obtained. In this day of increased patient sophistication, communication, and advocacy, obtaining consent is a very significant integral part of patient care, not just an after thought.
College of Physicians and Surgeons of SaskatchewanThe only comment I would make with respect to the consent to treatment document is that it may wish to comment about the physician’s ability to apply to the Capacity and Consent Board under sections 37 and 21 of the Act if the physician believes that the proxy is not acting according to the incapable person’s wishes, or contrary to their best interests.
I am responding to the request for comment on The College’s Consent to Medical Treatment policy.
In the main, the current version is clear, understandable, logical and comprehensive.
Referring to the definitions contained in the Health Care Consent Act:
“ ‘Treatment’ is anything that is done for a therapeutic … diagnostic or other health-related purpose … ”
The need for informed consent when interventions consist of administration of drugs or substances, surgery or application of physical measures is well understood. However, the need for informed consent for diagnostic evaluations is less widely recognized.
The diagnosis of certain medical conditions creates a duty of mandatory reporting. Episodic loss of consciousness, such as occurs with epilepsy or syncope (fainting) and excessive daytime somnolence are conditions likely to be reportable.
Patients believe that doctors have a duty of confidentiality. It is not well known that mandatory reporting requirements create exceptions. Section 203 of the Highway Traffic Act is one example (i).
In some cases, referral to specialists creates a foreseeable risk that the consultation will confirm a reportable condition. The current reality is that any reporting under Section 203 of the Highway Traffic Act results in immediate summary suspension of driving privileges and these may be difficult to recover. The loss of driving privileges can be anticipated to have negative lifestyle implications and in some cases, serious negative economic implications.
Many patients who have lost driving privileges through mandatory reporting feel that they have been inveigled into making voluntary self-disclosures, contrary to their interests.
Specialists in neurology and sleep medicine have come to recognize that patients need to be “Mirandized” in advance of referrals that might place driving privileges at risk.
I suggest that the need for informed consent ahead of referrals with potential negative administrative implications needs to be more clearly communicated to practicing physicians.
(i) “Every legally qualified medical practitioner shall report to the Registrar [i.e. Registrar of Motor Vehicles] the name, address and clinical condition of every person sixteen years of age or over attending upon the medical practitioner for medical services who, in the opinion of the medical practitioner, is suffering from a condition that may make it dangerous for the person to operate a motor vehicle.” R.S.O. 1990, c. H.8, s. 203 (1)
The Canadian Medical Protective AssociationThe CMPA has no issue with the principles outlined in the existing Policy, Consent to Medical Treatment. These principles articulated in the Policy primarily reiterate the legal requirements imposed by Ontario’s Health Care Consent Act.
As the College is aware, the CMPA has considerable expertise with respect to issues of consent. We are pleased that the Policy identifies the CMPA’s publication, “Consent: A Guide for Canadian Physicians” as one of the resources for physicians on issues related to consent. The Policy currently refers to the third edition of the CMPA’s Guide, which was published in 1996. Since that time, the CMPA released its fourth edition of the Guide in 2006. The updated Policy should make reference to the most recent edition of the Guide.
The College may also wish to consider referencing some of the CMPA’s other, more recent, publications on consent, including “Consent and minor procedures – What physicians need to know” (published in December 2012) and “Is this patient capable of consenting” (published in June 2011). These articles and the Consent Guide are available online at: http://www.cmpa-acpm.ca.
Given the CMPA’s experience with issues concerning consent, consideration may be given to including in the updated Policy a statement encouraging physicians to contact the CMPA for advice on this subject, especially when dealing with complex or contentious situations (e.g. identification of an appropriate substitute decision-maker).
Board of Directors of Drugless Therapy - NaturopathyThe current policy provides thorough direction on providing ethically and legally sound patient care, which is crucial for all health care practitioners. The Board supports the principle of this policy and has no specific feedback at this time. We look forward to reviewing the policy, once revised.
Medico-Legal Society of TorontoResponse in PDF format
University Health Network - Bioethics TeamThank for the opportunity to contribute to your review of the CPSO’s current policy regarding consent to medical treatment. On behalf of the bioethics team at University Health Network and our experience working with physicians in their daily work, I would like to recommend inclusion of the following points or clarifications:
1. Whether a patient’s physician can delegate to another physician the responsibility for getting consent for a particular medical treatment
2. Whether a patient’s physician can delegate to another allied health team member (e.g., nurse) the responsibility for getting consent for a particular medical treatment
3. When a physician finds a person incapable for treatment decisions, isn’t the physician required to proactively inform the person that he/she can appeal the finding to the Consent and Capacity Board?
4. As stated in the policy’s Emergency Treatment of Without Consent: Capable Person section, a physician is permitted to treat if “there is no reason to believe that the person does not want the treatment.” This point is excluded in the section about emergency treatment of an incapable person. If a physician has reason to believe the incapable person does not want treatment, isn’t it correct that the physician should not initiate the treatment?
5. Since many patients and families are unfamiliar with the legally-prescribed substitute decision maker hierarchy (as per HCCA), physicians themselves may need to explain the hierarchy to patients/families to ensure sound consent processes are understood and take place
6. Physicians are encouraged to support their healthcare organization’s efforts to educate patients and families about advance care planning measures such as the SDM hierarchy, Powers of Attorney for Personal Care, and SDM responsibilities
College of Physicians & Surgeons of AlbertaResponse in PDF format
Consent must be informed:
The reality is that consent does not really need to be informed consent. A physician does not have to provide the patient with details other than that surgery is necessary. The patient can be intimidated into not asking the questions which need to be asked.
If the patient’s husband sees that his wife does not have enough information and personally requests more information, the doctor can still be evasive. Questions do not have be answered.
Consent must not be obtained through fraud or misrepresentation:
The reality is the physician does not have to be frank and honest when advising the patient he or she needs surgery. Furthermore, in order to protect himself, the physician does not have to be frank and honest in his response to the College. The CMPA defends the doctor at all costs, and sometimes, when implied consent has been obtained through fraud or misrepresentation, from what I can see, the lawyers’ job is to defend the doctor, and the lawyers and their hired guns (medical experts) do their job exceedingly well.
The reality is that the CPSO is not required to perform “exhaustive” investigations, and therefore frivolous investigations, which do not ask whether the patients’ surgeries were actually necessary take place.
The College Investigator gets paid for performing a frivolous investigation, and the doctor gets paid for performing an unnecessary surgery.
The lawyers hired by the CMPA earn their money, and it’s just good for their business to keep defending the doctor. Chances are the lawyers and their medical experts will be given repeat business.
Evidence of Consent:
“Although the Act states that consent to treatment may be express or implied, physicians are strongly advised to obtain express consent from the patient.”
The reality is no evidence of consent is needed. I believe that when there is no signed consent, the College should ask the doctor “why?”.
The reality is the CPSO’s policy does not protect the patient. If the doctor chooses not to follow the policy, the CMPA will do their best to ensure he is not held accountable.
The CPSO’s investigations are inadequate to ensure their policies are upheld, and this is the real problem, in my opinion. Patients need an organization to protect them which is as powerful as the CMPA in protecting doctors.
While I fully support doctors being protected, the system should not permit and promote fraud.
The reality is that it does, in my opinion.
Advocacy Centre for the ElderlyResponse in PDF format
As an Ob gyn in Ontario I have discussed all the complications with the patient and witnessed the consent with the patient. In the office I have a consent form that outlines all the complications of surgery. However in the hospital we have a generalized consent form and even if you explain the complications of surgery and get the patient to sign the form, you must document in the chart that you have explained every complication ( you have to list the complications that you have explained not a statement that ” complications of the surgery were explained”). If you do not do this you will be viewed by the college as you have not explained the risks of surg ( not documented not explained is the rational) Since the cases that come via emergency are sometimes life threatening, Could the college make a sample surgical consent that they feel explaines the relevant complications so that the patient can sign this and we can get onto the treatment. This could then be a template for hospitals to use Medical templates could also be made. Also in my field our consent for delivering a baby reads “consent for labour and delivery has been obtained” What am I to document in the chart when a patient comes into labour regarding the risks of delivery?
Ontario Medical AssociationThe Ontario Medical Association welcomes the opportunity to comment on the College of Physicians and Surgeons’ consultations on two policies: Treating Self and Family and Consent to Medical Treatment. We have not identified any concerns with either policy at this time. We believe that the policies clearly and adequately set out expectations for physicians. We are also comfortable that the policies direct physicians to appropriate legislation including the Health Care Consent Act. Our only suggestion would be to include references to relevant publications of the Canadian Medical Protective Association (CMPA) which provide physicians with very practical advice in navigating issues that may come up with respect to treatment and consent.
Thank you for–accepting these comments.
I think that doctor’s have to continue to
be able to keep their religeous views and
that the government should have no right to
make them do procedures against their beliefs